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Cheer of home visits has become a chore

I have finally written a thing I never thought I would need: a home visiting protocol. Why? Because the thing I loved the most as a medical student has turned into a pet hate.

The joy used to be that you could go to see people just because they were lonely, or to check up on them before they became ill. (Isn’t that called preventive medicine?). You also had colleagues to work with in the community – the district nurses were easy to chat to because they were in the surgery too. You didn’t spend half an hour trying to find which form to fill in because there weren’t any forms – what nirvana!

I recall fondly my first GP attachment at medical school. It was in a small, terribly well-to-do practice somewhere in rural Nottinghamshire and I was bored to tears. The brief respites were the home visits.

The GP was a ‘proper’ doctor – male, mid-50s, white, nice two-seater sports car. He ticked all the boxes, and arrived in his impeccable suit with leather bag in hand.

Home visits gave me a way to nose round other peoples' homes without being arrested

I trailed behind looking awkward in my one pair of smart trousers from New Look and a creased jumper rescued from the wash that morning.

He was greeted like an old friend, offered tea, biscuits, and not infrequently lunch, by all the patients. There was little medicine, and a lot of chatting. It was fascinating in a way that the surgery wasn’t; I had found a legitimate route to nosing around other people’s homes without being arrested. General practice had it nailed.

But at some point, time pressures grew and only poorly people got home visits. Even then not all of them were acutely ill, some were still chronic disease patients or the frail elderly. Now workload is so bad I have time for one, maybe two visits max.

Yet home visit requests now flood in from other health providers wanting us to take up their slack. Why am I being called to review the palliative patient in the nursing home? Has anything changed, are they distressed, is the family worried? ‘No doctor, but we weren’t sure if they were palliative or about to die…’ And it just keeps increasing: discharged from hospital – home visit; rung 111 – home visit; can’t get a taxi – home visit.

Perhaps it is that the number of cups of tea I’m offered has fallen as demand has risen, but there seems to be no appreciation from the system, or from the patients, about how this once-cherished service is now being abused.

So I have written the protocol to try to educate patients about the harsh reality of general practice in 2018. Will it solve the problem for me? No chance, because again it’s about me having to say ‘no’ to patients.

I didn’t become a GP to ration care – we’re a band of eager puppies who want everyone to like us.

And let’s be honest, this is another nail in the coffin of the ‘jewel in the crown’ of the NHS (along with the three-week waits and ever-decreasing staff). When the NHS dissolves into private practice, maybe I’ll regain my joy about home visits.

Perhaps I need the awfully nice folks to fawn over me with tea and biscuits to feel valued. Or maybe I just need time to do my job – now there’s a radical thought.

I enjoy visiting those that are truly in need of help and has no other means of getting that help other then a visit. It's a privilege to have all the trust in the world place upon me (patient has no other choice, can't exactly ask for second opinion home visit!).

Unfortunately the definition of "truly in need" seems to have been diluted down, both by patients and the regulators. Now, we do visits when we know patients can come to the surgery if their extremely concerned "mom need immediate visit" daughter could be assed to take 1/2 a day off work to bring her here.

As such home visits are no longer privilege or enjoyable. It is now an irritation which takes away service from those that are willing to make the effort.

IMO almost all home visits except truly end of life visits are a complete waste of time. We now only visit truly bed bound or chair bound patients. We phone triage every visit request and have reduced visits by 80% in one year. Most are either unnecessary, can come to surgery or can be done over the phone.

To be fair DrWho even the chair bound make it to hospital appointments and often to the supermarket. They too should be coming to us - assuming of course we are all in fit for purpose, easilydisabled access premises! We have a great Paramedic who’s previous job was admission avoidance who does about 80% of our visits after we’ve triaged them. The patients love her, she takes the time to do a really thorough job and we couldn’t function without her now.

The most frustrating visits I find are where the family are too busy to leave work and drive an hour to check on their relative so they call you to do, and don’t bother telling the patient. The only way to ration visits is to charge for it. If we start to say no to patients we are opening ourselves up to complaints and litigation

Some people still talk about calling in while you are 'on your rounds'. We changed 8 months ago to one visit doc - busy enough with 15,5000 patients, and now that patients get whoever is on duty rather than their own doctor doing it and maybe 2 others in the 'lunch hour' that have altered their behaviour a bit. With increasing numbers of people being carer cared we get lots of visits because the carer is 'not happy' usually because of dependent oedema. And by the time you get to the house the carer has gone and the patient can't give a history.

I think my worst is the patients who demand a home visit and then aren't there when you visit. One in particular I remember as he asked me if I wouldn't mind waiting 20 mins till he got back from shopping!

Home visits should be reserved for those who are truly house bound or dying. I would define this as needing the assistance of more than one person to get into a car. These people need care though and I wonder if now we are heading towards super surgeries one designated GP with interest in elderly and palliative care could look after everyone in this category thus providing the continuity of care that is so essential to this group. I think GPs DNS and palliative care nurses are best placed for this. Paramedics - I’m not sure yet - their skill seems very dependant on the jobs they have previously done and I am not sure that a paramedic qualification does equip you with the required skill set. In a resource stretched setting visits due to lack of transport need to be a thing of the past although perhaps ccg’s could look into some sort of subsidised transport to surgeries for patients..